Provider Demographics
NPI:1912362641
Name:VASQUEZ, JENNIFER ALISSA (PHD, LCSW-S)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ALISSA
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:PHD, LCSW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BALCONES DR STE 12078
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4257
Mailing Address - Country:US
Mailing Address - Phone:512-785-7757
Mailing Address - Fax:
Practice Address - Street 1:5900 BALCONES DRIVE
Practice Address - Street 2:STE 12078
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731
Practice Address - Country:US
Practice Address - Phone:512-577-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX542621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13663799OtherCAQH